HEALTH DECLARATION FORM
Name: __________________________ Temp: _______ Date: ______
Residence: ______________________ Time: ______ Sex: _______
Barangay: _______________________ Contact #: _________________
School/Office: ____________________________ Age: _____
SYMPTOMS (SIMTOMAS)
A. Sore throat (Sakit sa tutunlan)
B. Body Pains (Sakit sa Kalawasan)
1. Are you
experiencing C. Headache (Labad sa ulo)
(nakabati ba ka): d. Fever for the past few days (hilanat sa
niaging mga adlaw)
e. Loss of taste and smell (walay
pantilaw og panimhut)
2. Have you ever worked together or stayed in the same
closed environment of confirmed COVID-19 case? (May
nakauban ba ka o nakatrabaho nga tawo nga kumpirmadong
may COVID-19?
3. Have you had any contact with anyone with fever, cough,
colds or soarthroat in the past 2 weeks? (May nakauban o
nakasalamuha ba ka nga may hilanat, ubo, sip-on, sakit sa
tutunlan sulod sa duha ka semana)?
4. Have you travelled outside the Philippines the past 14
days? (Ni byahe ba ka gawas Pilipinas sa niaging 14 ka
adlaw)?
5. Have you travelled to area in the Philippines aside from
your home? (Ni adto ba ka sa ubang parte sa Pilipinas bukod
sa imong balay)? Specify: ____________________________
I HEREBY AUTHORIZED DEPED-TANJAY CITY DIVISION TO COLLECT AND
PROCESS THE DATA INDICATED FOR THE PURPOSE OF EFFECTING
CONTROL OF COVID-19 INFECTION. I UNDERSTAND THAT MY PERSONAL
INFORMATION IS PROTECTED BY R.A. 10173, DATA PRIVACY ACT OF 2012,
AND THAT I AM REQUIRED BY R.A. 11469, BAYANIHAN TO HEAL AS ONE
ACT, TO PROVIDE TRUTHFUL INFORMATION.
________________________________
SIGNATURE OVER PRINTED NAME
HEALTH DECLARATION FORM
Name: __________________________ Temp: _______ Date: ______
Residence: ______________________ Time: ______ Sex: ______
Barangay: _______________________ Contact #: _________________
School/Office: ____________________________ Age: _____
SYMPTOMS (SIMTOMAS)
A. Sore throat (Sakit sa tutunlan)
1. Are you B. Body Pains (Sakit sa Kalawasan)
experiencing C. Headache (Labad sa ulo)
(nakabati ba ka):
d. Fever for the past few days (hilanat sa
niaging mga adlaw)
e. Loss of taste and smell (walay
pantilaw og panimhut)
2. Have you ever worked together or stayed in the same
closed environment of confirmed COVID-19 case? (May
nakauban ba ka o nakatrabaho nga tawo nga kumpirmadong
may COVID-19?
3. Have you had any contact with anyone with fever, cough,
colds or soarthroat in the past 2 weeks? (May nakauban o
nakasalamuha ba ka nga may hilanat, ubo, sip-on, sakit sa
tutunlan sulod sa duha ka semana)?
4. Have you travelled outside the Philippines the past 14
days? (Ni byahe ba ka gawas Pilipinas sa niaging 14 ka
adlaw)?
5. Have you travelled to area in the Philippines aside from
your home? (Ni adto ba ka sa ubang parte sa Pilipinas bukod
sa imong balay)? Specify: ____________________________
I HEREBY AUTHORIZED DEPED-TANJAY CITY DIVISION TO COLLECT AND
PROCESS THE DATA INDICATED FOR THE PURPOSE OF EFFECTING
CONTROL OF COVID-19 INFECTION. I UNDERSTAND THAT MY PERSONAL
INFORMATION IS PROTECTED BY R.A. 10173, DATA PRIVACY ACT OF 2012,
AND THAT I AM REQUIRED BY R.A. 11469, BAYANIHAN TO HEAL AS ONE
ACT, TO PROVIDE TRUTHFUL INFORMATION.
________________________________
SIGNATURE OVER PRINTED NAME
HEALTH DECLARATION FORM
Name: __________________________ Temp: _______ Date: ______
Residence: ______________________ Time: ______ Sex: _______
Barangay: _______________________ Contact #: _________________
School/Office: ____________________________ Age: _____
YES NO SYMPTOMS (SIMTOMAS) YES NO
A. Sore throat (Sakit sa tutunlan)
B. Body Pains (Sakit sa Kalawasan)
1. Are you
experiencing C. Headache (Labad sa ulo)
(nakabati ba ka): d. Fever for the past few days (hilanat sa
niaging mga adlaw)
e. Loss of taste and smell (walay
pantilaw og panimhut)
2. Have you ever worked together or stayed in the same
closed environment of confirmed COVID-19 case? (May
nakauban ba ka o nakatrabaho nga tawo nga kumpirmadong
may COVID-19?
3. Have you had any contact with anyone with fever, cough,
colds or soarthroat in the past 2 weeks? (May nakauban o
nakasalamuha ba ka nga may hilanat, ubo, sip-on, sakit sa
tutunlan sulod sa duha ka semana)?
4. Have you travelled outside the Philippines the past 14
days? (Ni byahe ba ka gawas Pilipinas sa niaging 14 ka
adlaw)?
5. Have you travelled to area in the Philippines aside from
your home? (Ni adto ba ka sa ubang parte sa Pilipinas bukod
sa imong balay)? Specify: ____________________________
I HEREBY AUTHORIZED DEPED-TANJAY CITY DIVISION TO COLLECT AND
PROCESS THE DATA INDICATED FOR THE PURPOSE OF EFFECTING
CONTROL OF COVID-19 INFECTION. I UNDERSTAND THAT MY PERSONAL
INFORMATION IS PROTECTED BY R.A. 10173, DATA PRIVACY ACT OF 2012,
AND THAT I AM REQUIRED BY R.A. 11469, BAYANIHAN TO HEAL AS ONE
ACT, TO PROVIDE TRUTHFUL INFORMATION.
________________________________
SIGNATURE OVER PRINTED NAME
HEALTH DECLARATION FORM
Name: __________________________ Temp: _______ Date: ______
Residence: ______________________ Time: ______ Sex: ______
Barangay: _______________________ Contact #: _________________
School/Office: ____________________________ Age: _____
YES NO SYMPTOMS (SIMTOMAS) YES NO
A. Sore throat (Sakit sa tutunlan)
1. Are you B. Body Pains (Sakit sa Kalawasan)
experiencing C. Headache (Labad sa ulo)
(nakabati ba ka):
d. Fever for the past few days (hilanat sa
niaging mga adlaw)
e. Loss of taste and smell (walay
pantilaw og panimhut)
2. Have you ever worked together or stayed in the same
closed environment of confirmed COVID-19 case? (May
nakauban ba ka o nakatrabaho nga tawo nga kumpirmadong
may COVID-19?
3. Have you had any contact with anyone with fever, cough,
colds or soarthroat in the past 2 weeks? (May nakauban o
nakasalamuha ba ka nga may hilanat, ubo, sip-on, sakit sa
tutunlan sulod sa duha ka semana)?
4. Have you travelled outside the Philippines the past 14
days? (Ni byahe ba ka gawas Pilipinas sa niaging 14 ka
adlaw)?
5. Have you travelled to area in the Philippines aside from
your home? (Ni adto ba ka sa ubang parte sa Pilipinas bukod
sa imong balay)? Specify: _____________________________
I HEREBY AUTHORIZED DEPED-TANJAY CITY DIVISION TO COLLECT AND
PROCESS THE DATA INDICATED FOR THE PURPOSE OF EFFECTING
CONTROL OF COVID-19 INFECTION. I UNDERSTAND THAT MY PERSONAL
INFORMATION IS PROTECTED BY R.A. 10173, DATA PRIVACY ACT OF 2012,
AND THAT I AM REQUIRED BY R.A. 11469, BAYANIHAN TO HEAL AS ONE
ACT, TO PROVIDE TRUTHFUL INFORMATION.
________________________________
SIGNATURE OVER PRINTED NAME